Kybella: Will it be the Next Big Thing ?

Written by: Joe Niamtu, III, DMD

Rejuvenation of the aging face and neck is my vocation, my avocation and my passion. I have performed 1,000 facelifts and over 1,000 facial liposuction procedures. I therefore feel extremely qualified to discuss treatments to this area. If you have not already heard, Kybella (formerly known as ATX-101) is a drug that was approved today by the FDA for the treatment of fat fullness under the chin. Kybella is a drug that is injected into the tissue under the chin with the intent to dissolve some of the fat.

Kythera is an extremely reputable company and has been working on this project over the past several years. From the onset, they made the commitment to invest the time and money into developing this drug and did not take the short cut route to come to market for the quick buck. The researchers and physicians that headed this project are all extremely respected and qualified. I was invited to participate in the research/study at the onset but declined for several reasons. First and foremost, true clinical research requires a special set up in the researcher’s office. Clinical trials require a significant amount of time from the doctors and staff and the record keeping is a significant undertaking. I have an extremely busy surgical practice and the level of research attention required to participate in such a study would be too much of a distraction to my practice. Some of my friends that were participants in the Kybella project are very involved in drug research and have special sections of their practice and staff committed only to research. These are be the most qualified people to perform clinical research. The other reason that I declined to participate is because my practice is mostly surgical and my treatments to the fat under the neck are performed with liposuction and or facelift surgery, depending on the severity. A medical treatment such as Kybella would have less impact on a surgical practice like mine.

“Getting a shot to dissolve fat under the chin” sounds too good to be true or a dream come true. My goal with this post is to examine treatment of this region from various perspectives. It is impossible for any doctor or patient to make decisions about treating the submental area (the area below the chin and above Adam’s apple) without a firm understanding of the anatomy and most important, what is skin and what is fat.

The Anatomy

There are several types of changes to the submental area related to fat deposition and aging. Some patients that are not overweight simply have a deposition of fat under the chin and it may be hereditary and resistant to weight loss. It is not uncommon for some people to have genetic related areas of diet resistant fat on various parts of the body including hips, abdomen, cheeks and under the chin. This is very, very different from patients that have fat deposits related to obesity. Contours that are a result of being overweight can be improved with simple weight loss. Contours that are a result of hereditary isolated deposition will not respond as well to diet and exercise.

Given the above information, the patients shown in figure 1 have isolated fat under the chin and would be good candidates for dissolving with an injectable drug. The patients in figure 2 are not candidates for isolated fat injections because they have generalized fat, not isolated fat. Injecting a fat dissolving drug under the chin of these patients would simply result in a dent in that region because the rest of the face and neck has excess body fat. This is an extremely important concept. To put this in other words, a patient with isolated fat deposit under the chin who DOES NOT have generalized excess facial fat could do quite well with isolated treatment. This would be like doing body work on a car that only had an isolated region that needed painted. On the other hand, reducing an isolated section of fat in a person that has fat all around that section will not have a balanced result because the surrounding fat is not treated. In terms of rejuvenation it would be like painting only one door on your car when the entire car needs painted

Figure 1. These patients have isolated fat deposits and may be candidates for dissolving submental fat.

Figure 2. These patients ARE NOT candidates for dissolving fat with an injection as there fat deposition is generalized and not isolated. Removing a small amount of fat in these patients would result in a “dent” and not be a natural reduction.

The Biggest Problem

The biggest problem that I think is going to occur as this news begins to filter through the media outlets is that people with “Turkey Gobblers” are going to think this treatment is a miracle and panacea for a youthful neck. Again, this explanation is all about the anatomy. As patients age, numerous changes occur. The aging changes affect the bone, the fat, the muscles and the skin. In a nutshell, everything sags, bags and drags! In the submental and neck region, the deep muscles (platysma) which once formed a tight sling in youth begin to sag. Older patients have changes in their fat deposition and the sagging skin forms jowls and the dreaded hanging neck skin (“turkey gobbler”). If the reader does not get anything else from this post, they must understand that fat dissolving drugs such as Kybella (or liposuction) WILL NOT improve droopy, hanging skin that comes with aging. This is usually not a result of fat, but rather a result of excess, aging skin. In fact, in patients with excess skin and associated fat, removing the fat will actually make the dangling skin worse. THE ONLY WAY TO EFFECTIVELY TREAT THIS TYPE OF NECK AGING IS WITH CONVENTIONAL FACELIFT SURGERY. I capitalized the previous sentence intentionally to make that point. The patients pictured in figure 3 would have no benefit from Kybella or liposuction because their problem is from skin excess, not fat excess.

Figure 3. These patients have aging changes from excess skin and muscles and removing fat would have no positive impact on this type of patient. Fat dissolving injections are ineffective in this type of patient.

Pearl #1- Kybella or other “fat dissolving drugs” will not be effective in patients with skin excess. They will only be effective in patients with isolated submental fat.

Fat Dissolving Drugs

Fat dissolving drugs are nothing new and have been around for decades. They seem to come in and out of popularity every 5-10 years. Fat dissolving injection treatments known as Mesotherapy are popular with some practitioners in this country and around the world. Fat dissolving drugs have been met with variable amounts of success and failure. Searching the Internet for “mesotherapy complications” will make this point. One of the problems with many past fat dissolving treatments was the lack of standardization and much of it was “home brew”. Hopefully the researched backed Kybella, which is FDA approved, will provide a safe and effective non-surgical treatment.

Who Will Use It?

After the hype of Kybella dies down and doctors and patients figure out where and when to use it, the true results will manifest itself and this will decide whether it is a “hero or zero”. The first questions that patients and doctors will have is “how much does it cost?”, “how many injections are required?”, “Will it work on everyone” and “what are the complications”. My prediction is that if this drug lives up to its promotion, it will be a procedure mostly used by non-surgeons. Many doctors from numerous specialties are involved in cosmetic treatments. Many of these doctors only offer non-surgical treatments which are extremely popular all over the world. This includes neurotoxins, fillers, skin treatments, non-surgical skin tightening and non-surgical fat treatment. Facial surgery is complex and requires years of advanced training. Non-surgical treatments are simpler and can be much more easily learned and mastered. Again, I think that non-surgical practices will more likely embrace fat dissolving treatments more than surgical practices.

Why Not My Practice?

I don’t think I will be using fat dissolving drugs in my practice to any significant degree. First off, I want to say “I don’t think so” as I have learned to never say never. If this therapy truly has a place and becomes a safe and effect treatment for selected patients, then I will be involved. The reason that I don’t think I will be providing a lot of these treatments is the fact that I know I can effectively treat isolated submental fat deposits in 10 minutes with local anesthesia and liposuction. Submental liposuction is a quick, safe and effective means to permanently remove or re-sculpt fat (figure 4 and 5). It is usually a onetime procedure and the recovery is minimal. More importantly, I can totally control and customize the fat removal and don’t have to rely on waiting to see what some injected drug will and will not do. So for me and thousands of other facial surgeons, there is not a great advantage of an injection over simple liposuction. For those doctors that don’t perform liposuction, the injectable produces may be a real advantage.

Figure 4. This image show a picture of liposuction being performed in the submental area. Note the yellow fat coming out of the tubing. This is a quick, safe and predictable treatment.

Figure 5. These images show actual liposuction being performed in the submental and jowl regions.

Figure 6. This patient was treated with liposuction and a chin implant. This is an excellent patient for liposuction as she is young and does not have excess hanging skin.

Figure 7. This patient underwent submental liposuction only. No other procedure was performed.

Like any new treatment, there will be victories and defeats during the early phases of treatment. I am sure that Kythera will control who has access to Kybella so that the initial treatments and results are safe and controlled. If this drug does prove to be safe, effective and affordable then it may become a viable non-surgical option in the treatment of isolated fat deposits under the skin. I am sure that there is also ongoing research for this drug to be used in the future for fat deposits elsewhere in the body such as the abdomen, hips, thighs etc.

Putting it all together

In my practice I treat isolated submental fat deposits with simple liposuction. For advanced facial aging and for the “Turkey Gobbler” neck, my go to procedure is facelift surgery. This is absolutely my favorite surgical procedure and I do almost one hundred facelifts a year and have done 1,000 lifts total. This is what excites me and this is why I love my job. There is no better feeling than reversing decades of aging on a patient. Figures 9-11 show before and after pictures of face and neck lift patients.